Products and policies may be provided by Horizon Insurance Company or Horizon Healthcare Dental, Inc. and services and products may be provided by Horizon Blue Cross Blue Shield of New Jersey or Horizon Healthcare of New Jersey, Inc., each an independent licensee of the Blue Cross and Blue Shield Association. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. © 2018 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105-2200.

2426 (0118)

January 29, 2018

Applies to: All Markets, excluding Medicare

Providing Form 1095-B Still Required by the ACA

On or about January 31, 2018, Horizon Blue Cross Blue Shield of New Jersey will begin mailing

Form 1095-B to members who either bought their coverage directly from Horizon BCBSNJ and not

through Healthcare.gov OR who have Horizon BCBSNJ coverage through their fully insured

employer-sponsored health plan. A sample of the letter being sent to members, along with a

sample 1095-B form, is attached.

Form 1095-B is informational and is issued to help our members comply with their responsibilities

under the Affordable Care Act (ACA); it does not need to be attached to federal income tax returns.

Form 1095-B includes the following information for members and their covered dependents:

• Name(s)• Last four digits of the Social Security Number(s) (SSN)• Date(s) of birth (if SSN is not available)• Months of fully insured health insurance coverage with Horizon BCBSNJ from

January 1, 2017 through December 31, 2017

Horizon BCBSNJ will report to the IRS the months that the fully insured member and their covered

dependents had qualifying health coverage through Horizon BCBSNJ. Horizon BCBSNJ can only

provide our members with the months that they and their qualified dependents had fully insured

Horizon BCBSNJ coverage. In addition to receiving the form through the mail, members with fully

insured coverage can also sign into Member Online Services at HorizonBlue.com to view their

form.

(Continues)

If a member had coverage through a different employer or insurer, the member will receive a form

from that employer or insurer. If a member bought their coverage through the Health Insurance

Marketplace, the member will receive Form 1095-A from the Centers for Medicare & Medicaid

Services (CMS).

Reporting obligations for self-insured groups

The ACA requires self-insured group health plans to be responsible for certain reporting

obligations. As a result, Horizon BCBSNJ will not provide the IRS with the months of qualifying

insurance on behalf of its clients with self-insured plans, nor will we send any information about

months of coverage to their employees. However, Horizon BCBSNJ may provide, upon request

from the group to their Account Manager, a data file containing limited information that may be

used in completing any required reporting.

This information should not be construed as tax or legal advice. Questions your clients or their

employees may have about their specific circumstances should be referred to their tax or legal

professional.

If you have questions, please contact your Horizon BCBSNJ sales executive or account manager.

Three Penn Plaza East Newark, NJ 07105-2200 HorizonBlue.com

CMC0011079 (0118) An independent licensee of the

Blue Cross and Blue Shield Association.

Re: Form 1095-B – Important Health Coverage Information for Your 2017 Taxes Dear Valued Member:

Under the Affordable Care Act (ACA), you are required to verify on your federal income tax return that you, and your spouse and/or individuals you claim as dependents, had qualifying health coverage (referred to as “minimum essential coverage”) for some or all months during the tax year. Individuals who did not have minimum essential coverage and do not qualify for an exemption may have to pay a penalty known as the “individual shared responsibility payment.” You must verify your qualifying health coverage or report your shared responsibility payment on line 61 of Form 1040, line 38 of Form 1040A or line 11 of Form 1040EZ.

What is Form 1095-B? The enclosed Form 1095-B provides information about your Horizon Blue Cross Blue Shield of New Jersey health insurance coverage to help you properly prepare your tax return for the Internal Revenue Service (IRS). Form 1095-B reports the names, addresses and Social Security Numbers1 (SSNs) of individuals covered under a Horizon BCBSNJ fully insured health plan and the number of months each member had coverage from January 1, 2017 through December 31, 2017. You do not need to attach Form 1095-B to your federal income tax return.

Why am I Receiving this Form? You are receiving Form 1095-B because either you bought your coverage directly from Horizon BCBSNJ and not through Healthcare.gov2 OR you have Horizon BCBSNJ coverage through your employer.

If you had Horizon BCBSNJ coverage through your employer during the tax year, see the Employer-Sponsored Coverage section (Part II) for information about your employer-sponsored coverage in 2017. Part III, Issuer or Other Coverage Provider, reports information about Horizon BCBSNJ.

Horizon BCBSNJ will report to the IRS the months that you and your covered dependents had qualifying health coverage through Horizon BCBSNJ. Horizon BCBSNJ can only provide you with the months that you and your qualified dependents had Horizon BCBSNJ coverage. If you changed employers in 2017, you may receive a separate Form 1095 from your other employer or insurance plan.

What You Need to Do • Talk to your tax professional for information about how to complete your tax return. • Review the information contained in Form 1095-B for accuracy. • If your information is incorrect, please call Member Services at the number on the back of your member ID card. • Keep Form 1095-B for your records. You do not need to attach it to your federal income tax return.

For More Information For more information about the individual shared responsibility payment under the ACA, visit irs.gov/Affordable-Care-Act/Individuals-and-Families/Individual-Shared-Responsibility-Provision. You may also visit HorizonBlue.com/faqs and select Social Security Number Collection and Reporting from the drop down menu, then select Form 1095-B from the drop down menu Horizon BCBSNJ cannot provide tax advice; if you need help with your taxes, please contact your tax advisor or consult the IRS with specific questions. Sincerely,

William Wolfe Director Billing, Enrollment and Account Installation

Enclosure

1 Date(s) of birth if SSNs not available. 2 If you or another family member received health insurance coverage through the Health Insurance Marketplace (also known as the Exchange), that coverage will be reported on Form 1095-A, not Form 1095-B.

Caution: Sample—NOT FOR FILING This is an early release draft of an IRS tax form, instructions, or publication, which the IRS is providing for your information as a courtesy. Do not file draft forms. Also, do not rely on draft instructions and publications for filing. We generally do not release drafts of forms until we believe we have incorporated all changes. However, unexpected issues sometimes arise, or legislation is passed, necessitating a change to a draft form. In addition, forms generally are subject to OMB approval before they can be officially released. Drafts of instructions and publications usually have at least some changes before being officially released.

Early releases of draft forms and instructions are at IRS.gov/draftforms. Please note that drafts may remain on IRS.gov even after the final release is posted at IRS.gov/downloadforms, and thus may not be removed until there is a new draft for the subsequent revision. All information about all revisions of all forms, instructions, and publications is at IRS.gov/formspubs.

Almost every form and publication also has its own easily accessible information page on IRS.gov. For example, the Form 1040 page is at IRS.gov/form1040; the Form W-2 page is at IRS.gov/w2; the Publication 17 page is at IRS.gov/pub17; the Form W-4 page is at IRS.gov/w4; the Form 8863 page is at IRS.gov/form8863; and the Schedule A (Form 1040) page is at IRS.gov/schedulea. If typing in the links above instead of clicking on them: type the link into the address bar of your browser, not in a Search box; the text after the slash must be lowercase; and your browser may require the link to begin with “www.”. Note that these are shortcut links that will automatically go to the actual link for the page.

If you wish, you can submit comments about draft or final forms,

instructions, or publications on the Comment on Tax Forms and Publications

page on IRS.gov. We cannot respond to all comments due to the high

volume we receive, but we will carefully consider each one. Please note that

we may not be able to consider many suggestions until the subsequent revision

of the product.

DO NOT FILE

Form 1095-B2016Department of the Treasury

Internal Revenue Service ▶ Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b.

OMB No. 1545-2252

560115

VOID

CORRECTED

Part I Responsible Individual (Policy Holder)1 Name of responsible individual 2 Social security number (SSN)

Sample, 20163 Date of birth (If SSN is not available)

4 Street address (including apartment no.) 5 City or town

6 State or province 7 Country and ZIP or foreign postal code

8 Enter letter identifying Origin of the Policy (see instructions for codes): . . . . . . . . . ▶

9 Small Business Health Options Program (SHOP) Marketplace identifier, if applicable

Part II Employer Sponsored Coverage (If Line 8 is A or B, complete this part.)10 Employer name 11 Employer identification number (EIN)

12 Street address (including room or suite no.) 13 City or town

14 State or province 15 Country and ZIP or foreign postal code

Part III Issuer or Other Coverage Provider16 Name 17 Employer identification number (EIN) 18 Contact telephone number

19 Street address (including room or suite no.) 20 City or town 21 State or province 22 Country and ZIP or foreign postal code

Part IV Covered Individuals (Enter the information for each covered individual(s).)

(a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not available)

(d) Covered all 12 months

(e) Months of coverage

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

23

24

25

26

27

28

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60704B Form 1095-B (2016)

560215Form 1095-B (2016) Page 2

Instructions for RecipientThis Form 1095-B provides information needed to report on your income taxreturn that you, your spouse, and individuals you claim as dependents hadqualifying health coverage (referred to as “minimum essential coverage”) forsome or all months during the year. Individuals who do not have minimumessential coverage and do not qualify for an exemption may be liable for theindividual shared responsibility payment.

Minimum essential coverage includes government-sponsored programs,eligible employer-sponsored plans, individual market plans, andmiscellaneous coverage designated by the Department of Health andHuman Services. For more information on minimum essential coverage, seePub. 974, Premium Tax Credit (PTC).

TIPProviders of minimum essential coverage are required to furnish

Sampleonly one Form 1095-B for all individuals whose coverage is reported on that form. As the recipient of this Form 1095-B, you

should provide a copy to individuals covered under the policy if they request it for their records.

Part I. Responsible Individual, lines 1-9. Part I reports information about you and the coverage.

Lines 2 and 3. Line 2 reports your social security number (SSN). For your protection, this form may show only the last four digits. However, the coverage provider is required to report your complete social security number to the IRS. Your date of birth will be entered on line 3 only if your SSN is not entered on line 2.

▲!CAUTION

If you don't provide your SSN and the SSNs of all covered individualsto the sponsor of the coverage, the IRS may not be able to match theForm 1095-B with the individuals to determine that they have

complied with the individual shared responsibility provision.

Line 8. This is the code for the type of coverage in which you or other covered individuals were enrolled. Only one letter will be entered on this line.

A.

Small Business Health Options Program (SHOP)B. Employer-sponsored coverageC. Government-sponsored program

E. Multiemployer planF. Miscellaneous minimum essential coverage

Line 9. This line will be blank for 2014.

Part II. Employer-Sponsored Coverage, lines 10-15. This part will be completed by the insurance company if an insurance company provides your employer-sponsored health coverage. It provides information about the employer sponsoring the coverage. If your coverage is not insured employer coverage, this part will be blank.

Part III. Issuer or Other Coverage Provider, lines 16-22. This part reports information about the coverage provider (insurance company, employer providing self-insured coverage, government agency sponsoring coverage under a government program such as Medicaid or Medicare, or other coverage sponsor). Line 18 reports a telephone number for the coverage provider that you can call if you have questions about the information reported on the form.

Part IV. Covered Individuals, lines 23-28. This part reports the name, SSN, and coverage information for each covered individual. A date of birth will be entered in column (c) only if an SSN is not entered in column (b). Column (d) will be checked if the individual was covered for at least one day in every month of the year. For individuals who were covered for some but not all months, information will be entered in column (e) indicating the months for which these individuals were covered. If there are more than six covered individuals, you will receive one or more additional Forms 1095-B that continue Part IV.